Can I Be Me?
Exploring Transgender People’s
Experiences of Transgender Healthcare
in Ireland and the Netherlands
Student Name: Niall Kirrane UVA ID: 12284327
Thesis Supervisor: Margriet Van Heesch Second Reader: Marci Cottingham
July 2019
Master of Sociology: Gender, Sexuality and Society Faculty of Social and Behavioural Sciences
N. Kirrane 2 Table of Contents
Acknowledgements ... 4
Research Summary ... 6
Chapter 1: This Is What Transgender Looks Like ... 7
1.1. Introduction ... 7
1.2. Defining Terms ... 8
1.3. 100 Years of Medicalisation ... 9
1.4. Transgender Scholarship ... 9
1.5. The Irish Context ... 11
1.6. The Dutch Context ... 13
1.7. Research Aims ... 14
Chapter 2 – Research Methodology ... 16
2.1. Introduction ... 16 2.2. An Ethical Methodology ... 16 2.3. Information Finding ... 18 2.4. Participant Recruitment ... 19 2.5. Data Collection ... 20 2.6. Participant Demographics ... 21 2.6.1. Participants in Ireland ... 21
2.6.2. Participants in the Netherlands ... 22
2.7. Data Analysis ... 23
Table 1: Irish Participant Demographic Information ... 24
Table 2: Dutch Participant Demographic Information ... 25
Chapter 3: Theorizing Transgender ... 26
3.1. Introduction ... 26
3.2. Doing Transgender ... 26
N. Kirrane 3
3.3.1. Foucauldian Discourse ... 28
3.3.2. Transnormativity ... 30
3.4. The Transgender Body as a Project ... 31
3.5. Conclusion ... 32
Chapter 4 – Transitioning in Ireland ... 33
4.1. Introduction ... 33
4.2. Waiting Times ... 33
4.3. Staff Expertise ... 35
4.4. Gatekeeping: Jumping through Hoops and Passing the Test ... 36
4.5. Production and Reproduction of Narratives ... 40
4.6. Gender Dysphoria ... 42
4.7. Motivations for Medically Transitioning ... 43
4.7.1. Personal Motivations ... 43
4.7.2. Social Motivations ... 44
4.8. Conclusion ... 46
Chapter 5 – Transitioning in the Netherlands ... 47
5.1. Introduction ... 47
5.2. Waiting Time ... 47
5.3. Staff Expertise ... 48
5.4. Gatekeeping: Jumping through Hoops and Passing the Test ... 50
5.5. Production and Reproduction of Narratives ... 53
5.6. Gender Dysphoria ... 55
5.7. Motivations for Medically Transitioning ... 56
5.7.1. Personal Motivations ... 57
5.7.2. Social Motivations ... 57
5.8. Conclusion ... 59
N. Kirrane 4
6.1. Introduction ... 60
6.2. Summarising & Comparing Contexts ... 60
6.3. ‘Trans’ as Discourse ... 62
6.4. An Informed Consent Model of Transgender Healthcare ... 64
6.5. Doing Transgender in Social Interactions ... 65
6.6. Conclusion ... 68
Chapter 7: This Is Me – A Reflective Conclusion ... 70
Bibliography ... 73
Appendix 1: Informed Consent Form ... 78
Appendix 2: Interview Schedule ... 81
N. Kirrane 5 Acknowledgements
This project represents the summation of a wonderful year in Amsterdam and a stimulating and rewarding return to academia. Moving my life to Amsterdam was not a decision that I made lightly, however it has proven to be more academically and personally enriching than I could ever have imagined. In addition to this wonderful city, there are a number of people I would like to thank, without whom I would not be who or where I am today:
• Firstly, I am indebted to the 18 wonderful people who participated in this project and shared with me their valuable insights and experiences. Together, I am sure we can bring about change for the better, in Ireland and the Netherlands.
• Thank you to my thesis supervisor, Margriet Van Heesch, for her constant encouragement and unique ability to instil confidence and positivity in my project, even when I myself was lacking it. Thanks also to my second reader, Marci Cottingham, for her inspiring teaching and academic guidance throughout the year which were formative to the making of this project.
• Thank you to my family and friends for the encouragement, patience and distraction that they provided this year when I needed it most. A special word of thanks to my Dad, who made doing this Master’s possible, and who has always instilled in me the joy and value that can be found in education.
• Finally, thank you to my partner in life, Pedro, for the selfless love and support he has provided me with over the past six years, but most especially in the past year as I pursued this dream.
N. Kirrane 6 Research Summary
Transgender healthcare involves medical interventions that are provided for people who identify as transgender (henceforth referred to as ‘trans’), to support their gender transition (Pearce, 2018). These often involve, but are not limited to, hormonal replacement therapy and surgical procedures. However, the provision and standards of transgender healthcare vary across national contexts and are widely debated in transgender studies and sociological literature (Johnson, 2018). Therefore, the aim of this research is to add to this body of knowledge, by exploring the experiences of trans people who have accessed transgender healthcare in Ireland and the Netherlands. In doing so, I hope to also establish how they view transgender healthcare generally, as well why they choose to access it.
A qualitative research approach was adopted to carry out this project, involving 18 semi-structured interviews conducted in Ireland and the Netherlands. A thematic analysis of this data (Braun & Clarke, 2006) then led to a set of results from each national context that could be compared and contrasted. Theories from the social constructivist approach within Sociology were applied to help make sense of how transgender identities are understood and constructed from a medical perspective (Pearce, 2018), and the challenges this can lead to. The work of Catherine Connell (2010) on ‘Doing Transgender’ was also applied to highlight how medical interventions can support trans people in redoing and undoing gender in new ways.
The results of this study show that a number of service differences exist between transgender healthcare in Ireland and the Netherlands, which led to more positive experiences being reported by participants who had accessed care in the Netherlands. However, this research also shows that all participants across both contexts had significant critiques of transgender healthcare as it is currently provided, suggesting that the current model of care no longer suits the community which it intends to serve. As a result, I suggest that new ways of providing transgender healthcare, such as the Informed Consent Model, be investigated in Ireland and the Netherlands. Furthermore, consultation and involvement of trans people in this process are crucial its success.
N. Kirrane 7 Chapter 1: This Is What Transgender Looks Like
1.1. Introduction
Dr. Sidhbh Gallagher is an Irish plastic surgeon currently working in the United States, where she is the founder and director of the ‘Transgender Health and Wellness’ programme in Indianapolis University Hospital. There she provides gender affirmation surgeries for transgender (trans) clients, most commonly chest masculinisation / top surgery (for trans men) and vaginoplasty / bottom surgery (for trans women). A range of other surgeries are also advertised through her website, including facial feminisation surgery, lip feminisation surgery and body contouring. While gender affirmation surgeries are offered to all, notably there are many more specific procedures catered solely towards transgender women, with fewer surgeries on offer for transgender men. Dr. Gallagher’s Instagram account (Gallagher, n.d.) provides photos and testimonies from her many trans clients, who have undergone top or bottom surgeries. All of the featured clients provide hugely positive reviews of both the results of their surgeries as well as their experience working with Dr. Gallagher. Following a brief narrative about the person, a number of hashtags are used in order to boost the post’s popularity and findability through social media. These tags range from medical terms relating to the specific procedures, such as ‘#mastectomy’ and ‘#doubleincision’, to terms borrowed from trans activism such as ‘#transenough’ and ‘#thisiswhattranslookslike’. The daily posts shared through this account, and the juxtaposition of hashtags such as the above, present one example of how medical interventions have become an important component of many people’s gender transition. In doing so, they have become connected and intertwined with the trans identity and what it indeed means to be trans.
However, the relationship between gender transitioning and medicine, as well as the two communities that lie behind them, has proven to be a fraught one, and the subject of much sociological inquiry and debate. In this introductory chapter, I hope to first define some of the key concepts that will be used in this thesis, before providing a brief overview of the history of transgender medicine, and what sociological scholarship has had to say about it. Following this, I will discuss the state of transgender healthcare in Ireland and the Netherlands, highlighting the lack of research that exists in this area, and explaining how I hope to address this gap.
N. Kirrane 8 1.2. Defining Terms
From the outset of this project it is important to clearly define the main terms pertinent to my research question, related to who I will be working with as well as what phenomenon I will be investigating.
In the use of the word transgender (sometimes abbreviated to ‘trans’), this thesis refers to individuals who do not identify with the gender that they were assigned at birth. Transgender is an umbrella term, used to refer to many such identities, including trans men, trans women, and also those who do not identify within the gender binary of male and female, such as non-binary or gender queer individuals (Trans Equality Network Ireland, 2018). The differentiation between someone’s gender identity (as an innate sense of feeling male, female, or somewhere in between), and one’s biological sex (defined by anatomy and designated at birth based on this) is key to understanding the term transgender (Association of Occupational Therapy Ireland, 2019). Furthermore, the use of a single term to describe this multitude of identities does not mean to say that everyone under the transgender ‘umbrella’ is the same or shares the same experience. Gender identities are as numerous and diverse as the people possessing them, and it is my hope that these research findings will illustrate exactly this.
The people in this study will be referred to using gender affirmative language, emphasising the gender they identify as, rather than the sex they were assigned at birth, as is often the case in medical texts (eg; male to female). Hence, trans men refers to individuals who identify as male, but were designated female at birth. And trans women will refers to individuals who identify as female, but were designated male at birth. Non-binary refers to individual who identify as neither male nor female, or who identify as somewhere in between. Transgender healthcare refers to the provision of medical services and interventions to support transgender individuals in achieving their transition aims. Most commonly, this consists of Hormonal Replacement Therapy (HRT) and surgical interventions which affirm one’s gender identity (Pearce, 2018). These are commonly categorised as top surgeries which involve breast construction or removal, and bottom surgeries which involve the construction or removal of a penis or vagina (Association of Occupational Therapy Ireland, 2019).
N. Kirrane 9 Medicalisation, the other key concept referred to in this project, has been defined by a variety of theorists from sociology and beyond (Busfield, 2017). Conrad, a key sociologist in the area, posits that medicalisation occurs when a human behaviour becomes defined as a medical problem, often resulting in the provision of medical treatment for it (Conrad, 1992). As a concept, Medicalisation often infers that the institution of medicine occupies a position of power in society, and therefore medicalisation of a behaviour or phenomenon can be used as a form of social control (Foucault, The Birth of the Clinic, 1973).
1.3. 100 Years of Medicalisation
Gender identity first became a concern of the medical field as the new discipline of sexology began to emerge in the early 20th century (Stryker S. , 2008). Magnus Hirschfeld, a German Jewish physician and sexologist, founded the Institute of Sexual Research in Berlin in 1919. He was a pioneering researcher and advocate for people whose gender identity did not match the sex assigned to them at birth, for whom he introduced the term ‘transvestite’ (Hirschfeld, 1948, p. 158). Hirschfeld offered ‘transvestite’ clients innovative medical interventions to try and alleviate their distress, and align their body with their gender identity. In doing so, he effectively formed the first gender identity clinic, and established a model for how contemporary gender services function today, equipped with teams of psychologists, psychiatrists, urologists, endocrinologists and surgeons.
While medical recognition and intervention offered a pathway for transgender people where few other options existed at the time, it resulted in non-normative gender identities becoming a medically diagnosable condition. The 1967 edition of the Diagnostic Service Manual (DSM) of the American Psychiatric Association (APA) saw the first inclusion of ‘transsexualism’ as a disorder of sexual deviation (Drescher, 2013). This diagnosis went on to become Gender Identity Disorder for many years, before the most recent reincarnation of Gender Dysphoria in the DSM 5 (American Psychiatric Association, 2013) which continues to be the diagnosis used to treat transgender individuals today.
1.4. Transgender Scholarship
The production of knowledge in relation to transgender identities was almost exclusively produced from a medical or psychological perspective in the second half of the 20th
N. Kirrane 10 century (Wanta & Unger, 2017). While authors from various medical disciplines published on potential causes and treatments for those who identified as trans, there was a notable voice missing from the conversation. That voice, of course, belongs to those who this literature was being published about, the voice of trans people themselves. In her ‘Post Transsexual Manifesto’, Sandy Stone wrote “The people who have no voice in this theorizing are the transsexuals themselves. As with males theorizing about women from the beginning of time, theorists of gender have seen transsexuals as possessing something less than agency” (Stone, 1992, p. 11). In a critical response to this issue, the field of Transgender Studies was established, in order to give a greater voice to the subjective and lived experiences of trans people, in a way that had not been done previously in the existing academic literature (Stryker, 2019).
A key topic that has been debated extensively by trans scholars has been the concept of medicalisation. Often, the literature describes the dual role and often contradictory effect that medicalisation has had upon the lives of trans people (Johnson, 2018; Spade, 2003). Medical professionals continue to occupy a position of power, acting as gatekeepers with the power of deciding who is eligible of availing of medical interventions, on the condition of meeting the strict diagnostic criteria set out by the medical community. This control and regulation has been found to be disempowering for members of the trans community, and the experience of receiving a diagnosis to be stigmatising. Yet the reasons why trans people engage with the medical model and ascertain a diagnosis of Gender Dysphoria are often related to being both legally and socially recognised as the gender they identify as (Davis, Dewey, & Murphy, 2016). Spade (2003) has written extensively about the dependence of legal systems on medical evidence, meaning diagnosis is a necessity in order for individuals to have their gender changed legally in many countries. Equally, in order to actually access healthcare and desired procedures, health insurance funding will only be granted to individuals with an official diagnosis of Gender Dysphoria (Johnson, 2015). In social contexts, having a ‘diagnosis’ of Gender Dysphoria can act as a way to help explain and legitimise the trans experience to others (Burke, 2011). In a society where scientific and medical knowledge is valued highly, it has offered trans people a narrative that is more easily understood and ultimately more believed by other members of a predominantly cisgender, heteronormative society. This can perhaps best be seen in the ‘born in the wrong body’ discourse that has become widely utilised, which
N. Kirrane 11 creates a dichotomy between one’s innate gender or gendered brain (the words ‘mind’ and ‘soul’ are often also inserted here) and the sexed body one is born in (Sadjadi, 2019)
The diagnosis of Gender Dysphoria lies at the centre of the medicalisation debate. The erasure of the word ‘disorder’ from the diagnosis (previously Gender Identity Disorder) came following much activism and pressure from within the trans community due to the pathologizing and stigmatising impact that such a label can carry (Johnson, 2018). This development can certainly be viewed as an improvement, however, it does not diminish the fact that Gender Dysphoria remains a diagnosable condition in a handbook of psychiatric conditions. Gender Dysphoria places emphasis on the distress caused by being in a body that does not align with one’s gender identity. In doing so it continues to locate the problem within the individual, rather than in a society that is frequently inhospitable and at times hostile towards people who identify in this way. In line with much transgender scholarship written in recent decades, Johnson (2018) argues that as long as gender dysphoria is framed as a clinical (rather than social) problem, then the resulting solutions on offer will be biomedical procedures rather than social change.
1.5. The Irish Context
In July 2015, Ireland became one of the world’s leaders in transgender rights by adopting the Gender Recognition Act (Government of Ireland, 2015), a policy which entitled transgender citizens to the legal right to self-determination of their gender. This enables them to change their official documents of identification (birth certificate, passport) based on how they view their gender, and without any requirement for medical evidence, as is the case in numerous other countries. However, while Ireland has made positive advances in its legal provision for transgender people, its healthcare provision for them remains critically under-developed.
People seeking to transition in Ireland generally do so through the public healthcare system. The only service for the country is currently based on the outskirts of Dublin in St. Columcille’s Hospital Loughlinstown (commonly referred to as ‘Loughlinstown’, as it will be in this thesis). Here, an Endocrinology unit serves a range of diverse patient groups, including people living with diabetes, people who are overweight, as well as transgender people who are medically transitioning. In order to access this service, transgender people must be referred to
N. Kirrane 12 the clinic by their GP, and have a confirmed diagnosis of Gender Dysphoria made by two independent professionals (either a Psychologist or Psychiatrist). Trans people must either organise this diagnostic process with a private service or else with the liaison Psychiatrist connected with the hospital. The Gender Identity clinic currently runs one day per week from Loughlinstown, and is staffed by one Consultant Endocrinologist who is supported by a team of junior doctors who are still completing their medical training. There are currently no surgical staff working as part of this team. While some surgical procedures required by trans men can be organised elsewhere in the public system (eg; mastectomies, hysterectomies), patients seeking all other gender affirmation surgeries have to travel abroad to get them. A small number of people who are seeking these services are publicly funded each year to travel abroad and have their gender affirmative surgery there, however the rest must self-fund themselves.
While trans clients have been seen in Loughlinstown since the late 2000s, the service has experienced an exponential increase in referrals in the past ten years, going from 10 cases in 2007, to 210 cases in 2017 (Bowers, 2018). Despite this, resources have not increased equally, resulting in a huge growth of waiting lists, currently standing at 2-3 years. Due to this lengthy waiting time, some trans people in Ireland elect to access private endocrinology services instead, however this necessitates the financial resources to do so, or the possession of private health insurance policy (which is not mandatory in Ireland).
Research suggests that approximately 1-2% of the population in Ireland experience gender variance, consistent with international estimates (Reed, et al., 2009). At current population levels, this would equate to approximately 50,000 – 100,000 people. What has become increasingly evident in recent years (as this estimate may well be rising) is that the current transgender healthcare service provision in Ireland is greatly lacking and under resourced. The resulting waiting times and lack of sufficient services have been shown to contribute to mental health difficulties and distress for trans people (McNeil, et al., 2013). Aside from long waiting lists, activist groups as well as reports in the media have criticised the service for holding a pathologized and binary view of gender identity (The Irish Times, 2018), as well as a failure to utilise standards of care guidelines created by WPATH (World Professional Association for Transgender Health, 2012), despite these being recognised internationally as best practice (Wylie, et al., 2016). Furthermore, 60% of trans people in Ireland have reported having a negative experience while accessing care in Loughlinstown (McNeil, et al., 2013). Cumulatively, this suggests that transgender people in Ireland are
N. Kirrane 13 experiencing a poor standard of transition related healthcare. Given the lack of research into the lives and experiences of trans people in Ireland generally (Health Service Executive, 2009), particularly with regards to healthcare, one of the goals of this thesis is to help address this gap in the literature.
1.6. The Dutch Context
The Vrije University Medical Centre (VUMC) based in Amsterdam, is regarded as one of the world’s leaders in providing transgender healthcare, as well as being the longest established gender identity clinic in Europe (Wiepjes, et al., 2018). Their specialised service for transgender people, entitled The Gender Dysphoria Knowledge & Care Centre, continues to be the main transgender healthcare provider in the Netherlands, however other regional services have been established in Groningen and Leiden (for children and adolescents). These services essentially follow the same model of care as the VUMC. The team at the VUMC consists of a large number of psychologists, who conduct the diagnostic process with every patient upon entry into the system. This is done through a series of individual monthly psychological meetings. Following these meetings, the psychologist presents their findings back to a multidisciplinary team. It is then decided amongst this team whether the person meets the diagnostic criteria of Gender Dysphoria, getting a ‘green light’ to begin transitioning, or not. In addition to the team of psychologists, there are also several Endocrinologists, plastic surgeons, and gynaecologists working on the gender team specifically, with a range of other specialities available within the hospital (Vrije University Medical Centre , 2019).
Despite the VUMC having a more established history of working with transgender clients than Loughlinstown, and significantly more resources in terms of staffing and funding, this service is also experiencing difficulty in managing the ever-increasing number of referrals that they are receiving, with their website stating that waiting time for a first intake interview may take years (Vrije University Medical Centre , 2019). Another important difference to outline for this study is the healthcare system in the Netherlands, which operates with mandatory state health insurance for each individual, paid for by the individual (with governmental assistance where necessary). In order to have treatments funded through their health insurance, trans individuals in the Netherlands rely upon the diagnosis of Gender Dysphoria to legitimise their experience and give access to the interventions they require.
N. Kirrane 14 A review of the literature illustrates that there is also a lack of research into trans people’s experiences of medicalisation in the Dutch context specifically. Online sources indicate that there are some common issues with the Irish context, such as the prohibitively long waiting lists mentioned above (Vrije University Medical Centre, 2019). However, the VUMC is notably different in that they are affiliated with WPATH and listed as a WPATH approved care provider (WPATH, 2012). Researchers belonging to the clinic have also acknowledged the diverse transition options they now provide, for example, no genital surgery (Beek, Kreukels, Cohen-Kettenis, & Steensma, 2015). In an official publication from the clinic they also state their commitment to working with client’s individual gender identities and transition preferences (T'Sjoen, Van Trotsenberg, & Gijs, 2013). This would seem to suggest that transgender people accessing care in the Netherlands experience a better standard of care than those in Ireland, however one of the goals of this thesis is to establish the veracity of this initial assessment.
1.7. Research Aims
As illustrated in the review of literature presented in this chapter, the medicalisation of gender transitioning on one hand provides trans people with interventions that support their legal, financial and social wellbeing. However, in doing so, can also pathologise and stigmatise what is a core facet of their individual identity. Therefore, this thesis suggests that transgender healthcare has the potential to be a transformative and supportive resource in the lives of transgender people, if provided in a way that is sensitive and inclusive of this community’s needs. As illustrated in the review of both Ireland and the Netherlands, differences exist in the provision of transgender healthcare between these two contexts. Given the lack of sociological research conducted specifically on this topic in these areas, I hope this research will establish how these differences effect the people using the services. Therefore, the main research question I will aim to answer in this Masters thesis is:
How do transgender people experience transgender healthcare in Ireland and the Netherlands?
To further support the aims of this project, this research will also investigate the following two sub-questions:
N. Kirrane 15 i) How do transgender people view the medicalisation of gender transitioning in
Ireland and the Netherlands?
ii) Why do transgender people choose to medically transition in Ireland and the Netherlands?
The following chapters will elaborate on the methodology employed to answer this research question, as well as the theoretical framework that guided it. Following this, the results of an empirical enquiry will be presented and discussed in relation to selected theoretical framework and the existing body of sociological knowledge on this topic. Finally, this thesis will conclude what can be learned from this project, and the sociological worth of exploring these questions.
N. Kirrane 16 Chapter 2 – Research Methodology
2.1. Introduction
In this research project, my aim was to explore transgender people’s experiences of using transgender healthcare in Ireland and the Netherlands. I chose to use qualitive research methods to do so, as I felt this was the most appropriate method for my topic and target population. Qualitative methods have been shown to help gain an understanding of the meanings and experiences of a phenomenon from the perspective of the research participants themselves (Hennink, Hutter, & Bailey, 2010). Many studies have been published on transgender identities from a variety of different disciplines, such as medicine, psychology and indeed sociology. However these publications have often lacked the voice of transgender people themselves (Stone, 1992). Therefore sharing my participants’ understanding and interpretation of medicalisation was of crucial importance to my research, from a methodological and ethical perspective. In line with this interpretative approach (Hennink, Hutter, & Bailey, 2010), I was also eager to gain an in-depth understanding of the contexts that my participants occupy and navigate, in both the social and medical contexts of Ireland and the Netherlands.
In this chapter I will outline how I planned and carried out the empirical research to try and answer my research questions. I will initially describe the important ethical considerations when undertaking a project like this, before discussing my recruitment of participants across two countries. I will then explain how I went about gathering and analysing the data which underpinned this project.
2.2. An Ethical Methodology
My interest in the area of transgender health came from my experience of working in a mental health service, where I had the privilege of working with transgender individuals amongst my other clients, and supporting them through different stages of their transition. My interest in the topic deepened upon starting my Sociology Masters in Gender & Sexuality Studies, prompting me to think more critically about transgender healthcare, and to also reflect more critically on the attitudes and assumptions I held regarding the role of medicine in gender transitioning. Despite having professional and personal connections with people who identify
N. Kirrane 17 as trans, I was acutely aware embarking upon this research of my own positionality. I am not trans. I identify as a cisgender male, and so see my role as an ally to the trans community rather than a constituent member. My standpoint had important implications for this research project, most especially in how I went about carrying it out.
As highlighted in Chapter 1, the voice of transgender people themselves has often been lacking in research produced about them. Adams et al. (2017) have highlighted how previous research carried out on transgender communities has also often been pathologising, insensitive in language use and lacking representation of the diversity of transgender identities. Therefore, I followed the helpful ethical guidelines devised by Adams et al. (2017) at all stages of the research process to ensure that I was not repeating the mistakes made by previous researchers that has damaged the relationship between then transgender community and academia. I will now discuss some of the key measures I took to address this.
Consultancy with transgender community members was a strategy I used frequently throughout my project, as Birt et al. (2016) have highlighted the importance of member checking strategies such as this. This was crucial at the conceptual stage of my project, when I made contact with the Health & Education Manager of the Transgender Equality Network Ireland (TENI). With her I discussed what my research interests were, and what she felt was a research priority for the trans community, especially in Ireland. We agreed that transgender healthcare was a cause of concern and one that needed further research and documentation. Furthermore she highlighted the differences that exist between the Netherlands and Ireland regarding transgender healthcare, and how this might be a useful comparison to draw. I also consulted with this person at various other points of the research process, regarding recruitment strategies and interview questions. A second member of the transgender community who is involved in trans activism, who was a personal contact of mine, was also of huge help to me during this project. He acted as a consultant to me to verify the appropriateness of language I was using in my research call out, communications and also the content of my interview schedule. His feedback was used to adapt these elements of my project, making them more suitable for use with transgender participants.
With regards to participants, written informed consent was obtained from each one prior to beginning each interview. A digital copy of the informed consent form (Appendix 1) was sent to participants in advance of their interview so that they had time to fully read and
N. Kirrane 18 consider it prior to meeting me for interview. Measures were also taken to ensure that participant’s anonymity was protected, if they wished. Participants were invited to provide a pseudonym for use in my research project to ensure they would not be recognisable. Some chose this option, while others were happy for their own name to be used. Furthermore, interview recordings were saved using a file number (eg; Interview 1), free of any personal identifying information. Both audio recordings and their associated transcripts were stored in password protected files on my encrypted personal computer. Finally, in line with the recommendations of Adams et al. (2017) to always share research findings back with the community, following submission of this thesis, I plan to create an infographic representing the key findings of this study. I plan to share this with all participants so that they can see what they have contributed to, and a full copy of my thesis will also be made available to them should they wish to read it.
2.3. Information Finding
A challenge that I encountered early on in the research process, was how little information was available publicly on the transgender healthcare services in either Ireland or the Netherlands. I consulted the websites of the Health Service Executive in Ireland, and the VUMC in the Netherlands, and while these both featured information on Gender Dysphoria and transitioning, they lacked any specifics regarding the processes and practices of their gender services. Therefore, in order to adequately inform myself on how each service worked in each context, I organised meetings with professionals working in the area. In March / April I met with two clinicians (one psychologist and one psychiatrist in training) working on the gender team at the VUMC, who provided an overview of how their service operated, and gave me a deeper insight into the national healthcare context of the Netherlands. I took detailed notes at these meetings, which informed my subsequent interviews and conversations with participants, as well as forming the basis for the national context information I provided in Chapter 1 of this thesis. Despite efforts to meet with a member of the gender team in Loughlinstown, my contact attempts received no response. As an alternative, I again met with the Health & Education manager of TENI, which is the principal trans advocacy group in Ireland. Through my discussions with her, I was able to formalise my knowledge on the state of Irish transgender healthcare.
N. Kirrane 19 In addition to this, I elected to travel to Rome in mid-April to attend the 3rd biennial European Professional Association for Transgender Healthcare (EPATH) conference. This event brought together over 600 attendees from all over the world, representing different areas of expertise relating to transgender health, such as clinical skills, education and human rights. Positively, the conference was also attended by a significant number of trans individuals this year. Through networking at this conference, I was able to speak with further clinicians from Ireland and the Netherlands, and also many other European countries, which allowed me to see how these two counties compare with international standards. Again, I took detailed notes following these conversations, and also during multiple highly informative presentations at the conference, which proved crucial to improving my understanding of transgender healthcare internationally, as well as in Ireland and the Netherlands.
2.4. Participant Recruitment
Based on the aims of my study and the parameters of my research question, I established the following inclusion criteria for recruiting participants:
- Identify as Transgender (Binary and Non-binary) - Adults, age 17+
- Experience of using transgender healthcare in Ireland / the Netherlands
- Willing to discuss their views and experiences of medicalisation (however participants will not be asked to discuss any medical procedures they may have had)
- Consent to being recorded for research purposes
My initial strategy for recruitment was to utilise transgender community groups in both Dublin and Amsterdam (major urban hubs of each country) to act as Gatekeepers in my recruitment process. Utilisation of a Gatekeeper has been shown to be beneficial for gaining access to a community in an ethical fashion, and also to potentially improve research participation (Hennink, Hutter, & Bailey, 2010). In Ireland, I contacted a number of organisations and community groups, including the Trans Equality Network of Ireland, the ‘This is Me’ activism group, as well as the LGBTQ societies in two of Dublin’s major universities. Unfortunately I experienced a number of barriers to recruiting in this way. Some informed me that due to their organisational policies, they no longer shared research call outs through their social media, as they felt it was an inappropriate use of a trans community resource. Another organisation reported they would be happy to share my call out, however
N. Kirrane 20 ultimately did not, and stopped responding to my requests to do so. To combat this, I shared my research call out through my own social media and social networks, where in turn it was also shared by others. Several trans friends of mine also posted my call out in closed, online community groups and forums that they belong to, and ultimately I believe this is where I obtained most of my participants from. In the end 12 people agreed to be interviewed, and I noted a sense of enthusiasm on their part, as they reported that they felt action needed to be taken regarding transgender healthcare in Ireland, and so were happy to contribute to such a project.
In Amsterdam, I also encountered challenges in my recruitment phase, however I was anticipating many of these. I contacted a number of community groups such as Transvisie and TransUnited. While these groups agreed to share my research call out, ultimately it obtained a poor response rate (2 participants). I believe that this was due to three factors: 1) As an international student living in this city, my social networks are not as well established here. Hence when sharing my call out on social media platforms, the local reach they had was limited. 2) As an international student living in Amsterdam, I also do not speak Dutch. Though the level of English proficiency in Amsterdam is high, asking participants to be interviewed in a language that is not their native one may have been a deterrent to participation. 3) Finally, perhaps due to the standard of trans healthcare in the Netherlands compared with Ireland, this research may not have been as pressing a concern for people, or at least of the people I was able to reach. Ultimately, I managed to conduct 6 interviews in the Netherlands, mainly through employing snowball sampling (Bryman, 2016) with the initial participants who responded to my research call out on social media. This presents the main limitation of this study, as due to more participants being interviewed in Ireland, it is likely that a broader array of experiences were identified, perhaps enhancing my understanding of transgender healthcare in Ireland more than in the Netherlands.
2.5. Data Collection
Data collection was done through semi-structured interviews with participants who responded to my research call-out. Demographic information was obtained using an online form that participants were required to fill in to register their interest in participating in this project. Hennink et al. (2010) describe semi-structured interviewing as a “meaning-making partnership”, highlighting how knowledge is produced, and meanings attributed to that
N. Kirrane 21 knowledge, through the interaction between interviewer and respondent. As such, I endeavoured to complete as many interviews in person as was possible, as I initially thought that this would be a better way of building rapport and trust with the participant. Therefore I spent three weeks in Dublin in April to gather data from the Irish sample there, and returned to Amsterdam to conduct interviews here following this. Due to several participants being located outside of Dublin / Amsterdam, or due to participant preference, I completed six interviews using Skype. I found these interviews to be equally productive, challenging my initial perception that Skype was an inferior way of carrying out research interviews.
The interviews were semi-structured in nature, and loosely followed the interview schedule I had devised in consultation with community members (see Appendix 2). The interviews initially took on a narrative format, in which participants recounted their transition journey and interactions with healthcare services in a chronological manner. However I followed this with a series of thematic questions relating to specific aspects of their experience, or broader questions relating to their views on medicalisation more generally. Interviews generally lasted one hour, and were recorded using the QuickTime audio recorder of my laptop.
2.6. Participant Demographics
In this section I will present an overview of the demographic information of respondents from both Ireland and the Netherlands. Full demographic information is also provided in Tables 1 and 2 at the end of this chapter.
2.6.1. Participants in Ireland
The Irish sample consisted of 12 people, six of whom identified as trans women, and six of whom identified as trans men. One of these participants also had an intersex condition, which she includes when describing her trans female identity.
Although all of these participants accessed transgender healthcare in Ireland, only four of them were born in Ireland. The other participants had migrated to Ireland from countries including Brazil, the United States of America, Denmark and the Netherlands. Ten participants had started their transition in Ireland, while the other two started their transition when they
N. Kirrane 22 were living in the United States. Two participants were no longer living in Ireland and therefore no longer accessing transgender healthcare there at the time of interviewing.
Of the twelve participants interviewed in this Irish sample, ten participants were accessing or attempting to access care from Loughlinstown. Two participants are currently on the waiting list, with one accessing a private Endocrinologist while they wait for their appointment with the public service. A further two participants are accessing their care through a private online service called Gender GP, however they are also on a waiting list for the public service in Loughlinstown, as a back-up option due to the somewhat un-certain future of an operation like Gender GP. Finally, the two remaining further participants had initially received care through Loughlinstown but have now managed to make an arrangement with their GP to continue prescribing their hormone replacement therapy.
2.6.2. Participants in the Netherlands
The six participants who participated in this part of the study were all currently residing in the Netherlands. Four of the participants were born there, one participant moved here at a young age from Brazil, and the final participant moved here in adulthood from Trinidad and Tobago. With regards to gender identity, four participants identified as trans women, one participant identified as a trans man, and the remaining participant identified as non-binary (using they/their pronouns). Participant ages ranged from 20 – 45 years old. All participants had accessed transgender healthcare in the Netherlands in the last ten years, with the majority accessing it in the last five years.
As discussed in Chapter One, the Vrije University Medical Centre Amsterdam (VUMC) is the largest transgender healthcare provider in the country. Five of the participants I interviewed had accessed medical care as part of their transition at the VUMC. One of these participants had initially accessed hormonal replacement therapy through a new healthcare initiative, run by a community organisation called TransUnited. This clinic is exclusively staffed by transgender people, including the prescribing doctor. As an organisation, Transunited aims to support transgender people, particularly those of migrant background and those working in the sex industry. Their clinic currently operates once per month in Amsterdam. The remaining participant interviewed in this sample is from the north of the
N. Kirrane 23 Netherlands, and therefore accessed her transition healthcare through the University Medical Centre Groningen (UMCG) due to living in their catchment area.
2.7. Data Analysis
I employed a thematic method of data analysis for this project, following the six step method of doing so outlined by Braun & Clarke (2006). Thematic data analysis aims to identify patterns that occur in the data set which are of importance or interest to the research question (s). I chose this method of data analysis to help me gain a deeper level of understanding about the meanings and themes in my data, going beyond what my participants had said. Due to the nature of my theoretical framework for this project, which draws upon a number of sociological traditions, I felt thematic analysis was workable with various epistemological and theoretical perspectives (Braun & Clarke, 2006).
I transcribed the audio recordings of my participant interviews using the programme Inq Scribe, which offers a number of keyboard shortcuts that are improve the speed and efficiency of transcribing. I used ATLAS.ti qualitative data analysis software to code each transcript following transcription. I found that it was more effective to do this immediately after transcribing while the data was fresh to me and I could record reflections I had, or patterns that I saw. I used open coding, which allowed me to develop and modify my codes as I progressed through my analysis. After coding all of the Irish sample interviews (n=12), I created some initial working themes, through combination of the more prevalent codes. In line with the method suggested by Braun and Clarke (2006), I then tried to identify themes occurring in the data, similar sentiments being expressed by multiple participants, or multiple times by one participant within the same interview. I then repeated this process for the Dutch sample interviews. I found that similar themes had emerged from both samples, and finally through combining various codes my themes were further refined. This enabled me to present them and relate them back to my theoretical framework in the chapters that follow.
N. Kirrane 24 Table 1: Irish Participant Demographic Information
Irish Sample
Name Gender
Identity* Pronouns Used Age Nationality Profession 1
st
Appointment:
1. Akira Trans man He/His 38 Brazilian Designer 2015
2. Beth Trans woman She/Her 30 Irish Unemployed Awaiting
3. Alice Trans woman She/Her 39 American Publishing
Administrator
2018
(Gender GP) 4. Claudia Trans female,
intersex
She/Her 48 Irish Student Waiting List
since 2017
5. Daphne Trans woman She/Her 45 Dutch Lecturer 2005
6. Joseph Trans man He/His 49 American Computer
Programmer 2000
7. Paul Trans man He/His 25 Irish Unemployed 2013
8. Jeremy Male He/Him 29 Brazilian Process
Analyst
2013
9. Jack Male He/Him 23 Irish Psychology
Student
2018
(Gender GP)
10. Sophia Female She/Her 29 Brazilian Crisis
management specialist
2018
11. Ollie Male He/Him 23 Irish Trans Rights
Activist
2015
12. Vanessa Trans woman She/Her 28 Danish Customer
Support Specialist
N. Kirrane 25 Table 2: Dutch Participant Demographic Information
The Netherlands Sample
Name Gender
Identity*
Pronouns Used
Age Nationality Profession 1st
Appointment w/ Service
1. Sebba Woman She/Her 20 Dutch Does not apply 2017
2. Thalia Trans woman She/Her 20 Netherlands Student 2018
3. Sam Non-binary /
Genderqueer
They/Them 24 Dutch Student 2019
4. Alexa Trans Woman She/Her 45 Trinidad &
Tobego
Sexual Health Worker
2009
5. Reinder Transman He/Him 20 Dutch Social Worker 2016
6. Jane Trans Woman She/Her 23 Dutch Student 2018
*Gender Identity was an open field, rather than closed set of options. The wording is therefore exactly how the participant themselves expressed their identity when completing the form.
N. Kirrane 26 Chapter 3: Theorizing Transgender
3.1. Introduction
Transgender studies scholar Blas Radi (2019) has recently discussed the challenges posed by the lack of a specific epistemology to draw upon in research related to transgender identities and issues. Radi highlights the various theoretical frames (eg; feminist theory, queer theory) that often are used in the absence of one clear epistemological tradition, however advises caution with regards to an uncritical application of these to transgender specific studies. Therefore in order to make my selection of a theoretical framework for this project, I have had to critically evaluate numerous influential theories and establish which would be most useful for guiding my research into transgender people’s experiences of healthcare. Ultimately, I will borrow from two different traditions of sociological research which I feel will benefit the analysis of my empirical data. In this chapter, I will first explore the potential of ‘Doing Transgender’ by Catherine Connell (2010) to support the findings of this study. I will then examine the social construction of transgender identities from a Foucauldian (1973) perspective, and examine the discourses that have been produced by the medical institution concerning them.
3.2. Doing Transgender
The theoretical framework I intend to apply in my research will be an elaboration on West and Zimmerman’s theory of ‘Doing Gender’ (1987). This theory stemmed from the symbolic interactionist approach within sociology, and hence gives greater attention to the agentic capacity of the individual actor, and also the importance of the many micro social interactions that occur in the daily life of the actor. Unlike more essentialist approaches to the conceptualisation of gender, that view gender as being part of the individual and in-built to their nature (Braidotti, 1994), gender is instead theorised as a “routine accomplishment” (West & Zimmerman, 2009, p. 126), achieved in social situations, in the presence (real or virtual) of others. West and Zimmerman provide three categories to help deconstruct and differentiate the multiple aspects that are at play in determining our own, as well as others, gender. While ‘Sex’ refers to the biological criteria that are used to determine if an individual is male / female / intersex, ‘Sex Category’ describes how people are also placed in one of these
N. Kirrane 27 categories based on their characteristics and displays - how they ‘do’ gender, rather than necessarily their sex. According to this theory, the word ‘Gender’ relates to the rules and guidelines for what is appropriate for one’s sex category.
The work of West and Zimmerman faced necessary critiques in the decades following its publication, which focused on its lack of acknowledgement on the influence of the social structures that people are said to ‘do gender’ in. However recent elaborations on the theory have applied the principles of ‘doing gender’ in new and contemporary ways, as well as welcome updates to the article made by the original authors themselves (West & Zimmerman, Accounting for Doing Gender, 2009). Catherine Connell (2010) explored how trans people operated and interacted in their workplaces, and found that trans people occupy a unique social location from which they have opportunities to continue doing gender, to undo gender in attempts to dismantle the gender binary, and to redo gender by re-defining the meanings and associations made within the binary. With the term ‘Doing Transgender’, Connell describes the potential trans people hold for disrupting the relationships between sex category and sex, which could be said to be embodied in trans people who opt not to go down a medical route of transitioning, or to those who opt for select procedures, where they themselves determine what parts of their body get to define their gender. Australian sociologist Raewyn Connell (2009) further elaborates on this potential in her discussion of social embodiment, and the new possibility for bodies that do not have to conform to fixed categories of gender.
Medical transition options may act as a support and vehicle to ‘doing transgender’, helping the individual to align their sex category with their gender identity in ways unique to the individual in question. For some, medical intervention may not be necessary to achieve this, for others varying degrees of medical intervention may be required. In this sense, gender can be undone and redone in as many different ways as there are individuals. Furthermore, the motivations and intentions behind this engagement (or lack of) with medical options may be better understood using an interactional theoretical framework, as empirical research has highlighted the socially motivated reasons why some people under go surgical or hormonal transitions (Johnson, 2018). In viewing gender as a social accomplishment, I hope to also explore who gender accomplishment and gender congruence is more important to, the individual or the medical professional?
N. Kirrane 28 In applying this theoretical framework, I intend to be mindful of its limitations, in particular its lack of emphasis on the social structures that social interactions occur in, and the power differentials that exist within these. As highlighted above, this is an important consideration given the focus of my project is on not just examining how trans people do, redo and undo gender, but also what role healthcare and the institution of medicine plays in controlling this. Therefore, in order to adequately address this, I will revert to back to the post-structuralist strand of sociology, to explore how this can help to make sense of the data obtained in this project.
3.3. (De)Constructing Transnormative Discourse
While Connell’s theory of Doing Transgender provides a useful framework for viewing why and how trans people undo and redo gender in new ways, it does not adequately account for the often limited range of options available to trans people in the first place, nor the role that the medical institution plays in regulating this. This project acknowledges the very real existence and materiality of trans individuals and identities, however I will turn to a social constructivist approach to establish how these individuals and identities are both understood and constructed differently through medical discourse.
3.3.1. Foucauldian Discourse
As a post-structuralist, Foucault dedicated much of his life’s work to exploring systems of power and oppression, and how individuals and groups in society are subjugated to these. Foucault’s notion of ‘biopower’ examined how people and bodies are controlled, regulated and invested with power by institutions such as the state, but also religions and indeed medicine (Foucault, 1976). Foucault posits that a crucial tool for operationalising this power is through the use of discourse (Shilling, 2012). Despite discourse being a major concept throughout Foucault’s work, he does not provide a precise definition of what it means, perhaps in his own bid to avoid setting definitive limits to the concept. However Shilling (2012, p. 79) describes discourse as “the link between daily practices and the organization and exercise of power”. Foucault highlights the important link between discourse and language, whilst also recognising that the concept goes beyond just language in that it also represents a way of thinking about social phenomena, such as gender and sexuality, which in turn changes how society deals with them (Foucault, 1976).
N. Kirrane 29 Foucault asserts that in the age of modernity, new relationships began to emerge between embodied subjects and systems of power, with science and medicine being crucial examples of these, particularly as the influence of traditional institutions such as the church declined (Shilling, 2012). Foucault posits that these changes resulted in increased control and regulation over bodies, as individuals were able to be distinguished and differentiated against population data (particularly relating to health) in a process he labelled individuation (Foucault, 1973). Foucault particularly references this when discussing how concepts of sexuality changed from being a series of acts and instead became an identity, a personhood, through which people gained an understanding of themselves and others (Downing, 2008). With the rise of the medical discipline of sexology in the 19th century, Foucault reported that sexual orientations and gender identities that deviated away from the heterosexual, male/female gender norm, became pathologized and othered, set in opposition to what was regarded as normal (Tosh, 2016). He viewed these healthy / natural -vs- pathological / unnatural distinctions as crucial to the medical field gaining respect and authority as a form of knowledge, in which “a new definition of the patient in society” (1973, p. 196) was required.
By applying the work of Foucault to trans individuals, we can come to view the term ‘trans’ itself as being socially constructed. While it is crucial to emphasise the reality and validity of trans identities, viewing it also as a socially constructed phenomenon can help us to understand the tension that exists between how the medical establishment defines what it is to be trans, and how trans people define it themselves. In her recent book, Pearce (2018) elaborates on how different discourses are used to construct the trans identity, based on different understandings of what it is to be trans. In doing so, she builds on Foucault’s (1973) view that discourses are not inactive descriptions of the world, but instead are active forces that reproduce how we see and experience the world. Due to the privileged position occupied by medicine in contemporary Western society, medical discourse defining the trans experience has been dominant for the past century, since the rise of sexology. According to Pearce (2018), the early figure of the transsexual emerged out of a “negotiation between practitioners and patients”, as trans individuals also actively sought out medical assistance to help them transition. This led to the discursive construction of ‘trans’ as a medical condition, an identity that was seen as both “fixed and fixable” (Pearce, 2018, p. 9).
N. Kirrane 30 3.3.2. Transnormativity
The power of this medical discourse is evident in its enduring existence to this day. Transnormativity is an emerging concept that not only acknowledges the existence of this discourse, but also highlights how it privileges and legitimises certain transgender identities and experiences based upon a medical model of transgender (Johnson, 2016). While some members of the trans community will choose to medically transition in accordance with these standards, transnormativity frames the problem that this transition process is used as the standard to compare all trans people to, regardless of their own intention or interest in medically transitioning. Parallels have been drawn between transnormativity and homonormativity, in that they both prioritise assimilation to heteronormative / cisgender standards of gender and sexuality, rather than contesting or challenging them (McIntyre, 2018). There are empowering and positive aspects of transnormativity, in that it has become a narrative that seems to be more easily understood by members of society, and so helps to legitimise and support trans individuals in their quest for equality. However, often this can come at the cost of further alienating other trans and gender non-conforming identities, subordinating them in a hierarchy based on existing and limiting gender norms.
McIntyre (2018) highlights the crucial influence that medical discourse has had on the evolution of transnormativity, through its focus on physical interventions and adaptations as a means of aligning a person’s body with their gender identity, in accordance with binary understandings of male and female. McIntrye proposes that by adhering to binary notions of gender, facilitated by the medical institution, trans people become “culturally intelligible” (p. 10) and hence more easily accepted by society. This re-enforcement of what it is to be male or female, based on corporeality and physical features leads to an essentialist approach to gender, posing problems for people of all gender identities. This is perhaps best encapsulated in the concept of ‘passing’, which refers to efforts made by a trans individual to be successfully perceived by others as the gender they identify as, often by meeting normative standards that society holds for that gender (Pearce, 2018). The concept of passing is strongly critiqued within transgender studies, with Sandy Stone (1992) calling upon trans individuals not to aspire to passing, and instead be consciously and obviously ‘read’ as trans, in order to highlight the diversity and reality of trans identities and experiences.
N. Kirrane 31 Medical trans discourses are often characterised by the use of the ‘wrong body’ discourse, which conceptualises a trans person as simply being born in the wrong body for their gender identity (Bettcher, 2014). This ideology, as well as the potential distress it causes, is evident in the structuring of Gender Dysphoria as a diagnosis, with many of its criteria aligning with this notion (American Psychiatric Association, 2013). Hence the wrong body discourse can be seen to play a role in the pathologizing of gender transition, reducing it to “an essentialist, symptom‐based model of trans experience” (Johnson, 2016, p. 469), thereby eliminating any acknowledgement of the possibility of gender fluidity or social influences upon this process. The agency and volition of the individual is also called into question by using the wrong body discourse, as it posits that this gender incongruence must be something inborn and discoverable, not something that an individual can decide at a point in their life based on their own personal journey and understanding of gender (Johnson, 2016). Thus, gender non-conformance becomes viewed as a medical condition, treatable through hormonal and surgical interventions, providing one meets the diagnostic criteria satisfactorily, as determined by medical gatekeepers. While this enables some trans people to transition from one side of the gender binary to the other, it often comes at the cost of those who fall somewhere in between (McIntrye, 2018).
Ultimately, medical discourses that define trans identities and experiences have served some positive functions for the community, by increasing the social intelligibility of trans people, and offering a formalised pathway to the care some may require. However in this project I hope to examine the suitability of this view for trans people living in Ireland and the Netherlands in 2019. To revert to Foucault (1973), it is clear that the knowledge production regarding transgender identities by the medical establishment has granted it the power of defining and controlling these identities, leaving little room for the self-identification and determination of trans people themselves.
3.4. The Transgender Body as a Project
A final theoretical influence from Foucault will be used in this project relating to the physical bodies of transgender individuals involved in this study. Foucault theorized that as new relationships began to emerge between embodied subjects and systems of power in recent centuries, individuals began to modify their bodies in order to align with their ‘inner’ or ‘true’ self (Foucault, 1973). This process of ‘self-formation’ is always influenced by societal
N. Kirrane 32 discourses, and therefore can lead individuals to utilize technologies upon their bodies in order to become the ‘social subject’ they think they should be (Shilling, 2012). Nikolas Rose further developed Foucault’s concept of self-formation with his work on the ‘Somatic Individual’, where he recognises that increasing efforts are being made by individuals to discover their ‘true’ self or identity through transforming their physical body (Heyes, 2007). The technologies referenced by Rose and Foucault vary, but include extreme dieting regimes, and cosmetic surgeries. However, I intend to utilise this theory to examine how transgender people can also potentially see their bodies as a project (Shilling, 2012), a canvas upon which they can make manifest their gender identities.
This also poses a question of bodily autonomy, and what limits there are upon what society permits an individual to do to / with their own body. This is a pertinent debate in the Irish context currently, following a national referendum in 2018 to decide whether to legalise abortion for the first time in the history of the state. The referendum passed successfully, following over thirty years of activism from Women’s groups, with the right to bodily autonomy central to their argument for legalisation. I intend to explore the potential this could hold for transgender people in Ireland in their quest to secure full bodily autonomy, and compare this with the Dutch context which has a history of church and state separation, resulting in a more secular and liberal society.
3.5. Conclusion
In this chapter I have outlined the various sociological theories that will underpin my research project, and help to both analyse and discuss the data obtained from participants, as will be presented in the subsequent chapters.
N. Kirrane 33 Chapter 4 – Transitioning in Ireland
4.1. Introduction
In this chapter, I will present the findings from the interviews I conducted with participants who have accessed transgender healthcare in Ireland. While some participants were accessing transgender healthcare outside of the main public service in Loughlinstown, the majority of views and experiences presented in this section refer to the public service (except where otherwise specified). The main findings from this sample will be presented using the most prominent themes that emerged from these interviews during the data analysis phase of this project. First, I will present participant experiences of waiting times, staff expertise, then the practices that constitute gatekeeping. I will then present the transnormative narratives that were reported, followed by how participants feel about the diagnosis of Gender Dysphoria, and finally what their motivations are for medically transitioning.
4.2. Waiting Times
The most frequent and unifying concern reported by all interview participants in the Irish sample related to the significant waiting times for accessing the public gender healthcare service in Ireland, based in Loughlinstown. All participants made reference to this at some stage in their interview, either as something they experienced in the past, or something they were still experiencing at time of interview. Depending on what year the participant started their transition appeared to influence how long they had to wait to access services. For example, Daphne started accessing services in 2005, and reported waiting a few months to do so, however for Beth and Claudia, who are in the process of trying to access services now, they have been advised that the may be waiting up to three years before they are seen for their initial consult. Ollie, who transitioned four years ago, discussed his views on waiting times:
I managed to get in before the services were way over-subscribed, but there were substantial waiting lists. I think the waiting times that I had were still unacceptable, and what they are now is absolutely ridiculous and I think they are a violation of people's human rights
Ollie’s sentiments highlight that waiting times are currently increasing for the service in Loughlinstown, indicating both an increase in the demand for services there, as well as
